Choice of anaesthetic and healthcare facility for third molar surgery

Comparison of safety of general anesthesia and intravenous sedation during third-molar extraction surgery

This study compared the safety of general anesthesia (GA) and intravenous sedation (IVS) in patients who underwent extraction of one or more third molars. Data from 1260 patients (GA group, n = 1043; IVS group, n = 217) were retrospectively analyzed, including demographics, preoperative data, intraoperative hemodynamic parameters (blood pressure, heart rate, and oxygen saturation level), and medications administered intraoperatively and postoperatively. The incidence of intraoperative circulatory variations, surgery and anesthesia durations, postoperative complications, and medication use were assessed and compared. The GA group had longer anesthesia and surgery durations, a higher incidence of hypotension, and a higher frequency of postoperative analgesic use than the IVS group. Dexmedetomidine was the most frequently used sedative agent. The IVS group had a lower incidence of intraoperative hypotension but they had a higher need for vasopressors in the recovery room. Both anesthesia methods maintained satisfactory oxygen saturation levels and sufficient anesthesia throughout the procedure, but they showed different characteristics regarding the duration of surgery and anesthesia duration, hemodynamic stability, and postoperative analgesic needs. IVS may be preferable for patients at risk of cardiovascular complications such as hypotension or tachycardia during surgery.

Assessment of Difficulty in Mandibular Third Molar Surgery by Lambade-Dawane-Mali's Index

PURPOSE

The evaluation of mandibular third molar (M3) difficulty is extremely important. This study aims to measure the association between preoperative Lambade-Dawane-Mali's (LDM) M3 difficulty index and postoperative assessment of difficulty score.

MATERIAL AND METHODS

This prospective cohort study included patients with impacted M3 reported to the Department of OMFS, RRK Dental College, Akola, from 2017 to 2022. The preoperative surgical difficulty was estimated using the predictor, LDM index with scores, easy (15-25), moderate (25-30), and difficult (>30). The postoperative surgical difficulty was analyzed with the primary outcome variable, total time intervention measured from the beginning of incision to the final suturing, wherein extraction was classified as easy if time (<15 minutes), moderate (15-30 minutes), and difficult (>30 minutes). The secondary outcome variable, Modified Parant's Scale (MPS), defines four levels of difficulty required for extraction of M3: Easy I (forceps extraction), Easy II (requiring osteotomy), Difficult III (coronal sectioning), and Difficult IV (complex extraction). Data were analyzed using agreement between LDM difficulty with three established criteria (time, MPS, Pederson index) and were assessed with Cohen's Kappa statistics. McNemar's test for paired data was used to assess concordance between two criteria of evaluation with a P-value <.05 was considered statistically significant.

RESULTS

The study sample included 1000 patients with a mean age of 26.7 ± 7.6 years and 456 (45.6%) females. Preoperative LDM difficulty assessed postoperatively by MPS indicated 99% were correctly identified by LDM preoperatively to have difficult and 99% easy outcomes. Inter-criteria agreement and Kappa statistics suggested a positive Kappa value (κ) and statistically significant agreement between the LDM index with perioperative time (κ = 0.8930), MPS (κ = 0.6488), and Pederson index (κ = 0.4920) at P-value 0.0001. Pair-wise comparisons of LDM criteria with perioperative time, MPS, and Pederson scale were assessed by McNemar's test, which evaluated concordance between the two criteria.

CONCLUSION

Postoperative evaluation of surgical difficulty in M3 extraction was strongly correlated with preoperative variables in the LDM difficulty-scoring index. Preoperative evaluation helps in envisaging the difficulty, planning surgical management, and helps in better time scheduling.

The influence of sedation and general anesthesia to patients' psycho-emotional status undergoing wisdom teeth extraction: a pilot clinical trial

Background: Patients usually face negative psycho-emotional status during teeth extraction, therefore sedation and general anesthesia are often selected for wisdom teeth extractions. The aim of this study is to evaluate the difference between sedation and general anesthesia patients' psycho-emotional status and pain, using Universal Scale in Oral Surgery for Psycho-Emotional Rating (USOS), Visual Analogue Scale (VAS) and Modified Corah's Dental Anxiety scale (MDAS). Methods: In the period of 10/21/2019–01/31/2020 a prospective control study was held of adult patients for extraction of four wisdom teeth with sedation or general anesthesia. Patients were evaluated using self-reported questionnaires and physician questionnaire. Results: In total 53 patients were included in study: 43 in the sedation group (SG) and 10 in the general anesthesia group (GAG). Patients' psycho-emotional status was significantly (p < 0.05) more negative in both groups at the day of surgery than before it, but the difference of fear was higher in GAG (p < 0.05). Immediately after surgery GAG (3.80) felt statistically significantly (p < 0.05) more pain than SG (2.60). Conclusion: Sum of USOS, MDAS, dental fear data scores, pulse measurements directly correlated with time, i.e. statistics increased as surgery approached. The pain sensation differences were found only in the assessment immediately after surgery.

Review of Difficulty Indices for Removal of Impacted Third Molars and a New Classification of Difficulty Indices

BACKGROUND

A number of efforts have been made to establish a reliable assessment model for the surgical removal of impacted third molars. Although many such models have been proposed, none is considered universally applicable, and controversy remains. The earlier attempts were based exclusively on radiographic variables, whereas recent evidence is associated with nonradiographic and demographic variables.

PURPOSE

This article aimed to prepare review of the relevant literature to summarize the important indices given till date, tabulating only new indices as old indices are mentioned in almost all text books, their merits and demerits and their specificity and sensitivity (if assessed in the literature). In addition to it, authors also aimed to introduce a new descriptive classification of all indices based on pre- and postoperative assessment and further classify based on clinical, radiographic and demographic factors, surgical technique and time. This article will be of academic and practical help for residents and clinicians.

METHOD

A literature search was conducted in Medline, PubMed, Google Scholar, Science Direct and Cochrane electronic database with keywords-impacted mandibular third molar, difficulty indices, validity of, sensitivity, specificity. No publication year limit was used. The abstracts of the articles were retrieved, reviewed and sorted based on the following inclusion and exclusion criteria. Articles which include a new index, validate difficulty index, compare two or more difficulty indices, specificity and sensitivity of particular index are included. Duplicate articles, articles on complication, flap design, drug study, radiographic relation of inferior alveolar nerve, suturing, classification, only assessing factor affecting difficulty of third molar surgery are not included.

RESULTS

Total 39 (36 articles + 3 books) are included. A total of 20 individual indices were found in the literature; each has been described in brief in this review. These indices are also listed in chronological order with their specificity and sensitivity if accessed in the literature.

CONCLUSION

There is a definite need to derive and validate an user-friendly index that could be used for preoperative prediction of difficulty. To the best of our knowledge, this review including all indices till date and classification proposed is the first on this subject.

Population pharmacokinetics of articaine with 1:200,000 epinephrine during third molar surgery and simulation of high-dose regimens

BACKGROUND AND OBJECTIVES

Articaine is more and more used in third molar surgery under local anesthesia (LA). The objectives of this analysis were to characterize the pharmacokinetics of articaine for this type of surgery and to simulate dosing regimens.

METHODS

Non-linear mixed-effects modeling conducted in Monolix 4.4.0 was used to describe articaine plasma concentration-time data from 20 patients. Monte Carlo simulations were then performed to evaluate the probability of cardiotoxic target attainment (PCTA) of various dosage regimens.

RESULTS

Articaine concentration data were best described by a linear one-compartment model, with an additional depot compartment for submucosal route with a zero-order transfer to central compartment. Age and gender were found to influence duration transfer (Tk0) and elimination rate constant (Ke), respectively. Simulated maximum recommended dose regimen (7mg/kg) had a PCTA of 0%. Simulated higher doses of 10mg/kg and 15mg/kg had a PCTA of 0% and about 1-4%, respectively.

CONCLUSIONS

The model adequately described the articaine pharmacokinetics. This is the first PK model qualified for articaine administered by submucosal route. The simulations suggest that maximum recommended dose regimen is safe concerning the cardiotoxicity in healthy patients.

Importance of Clinical and Radiological Parameters in Assessment of Surgical Difficulty in Removal of Impacted Mandibular 3rd Molars: A New Index

OBJECTIVE

The aim of the study is to assess the clinical and radiological factors that increase the surgical difficulty in removal of mandibular impacted 3rd molar and design a new difficulty predictive index.

METHODS

The data was collected from 100 patients with impacted mandibular 3rd molar who presented to Department of Oral and Maxillofacial Surgery, K.L.E's Institute of Dental Sciences. Clinical and radiological parameters included in the New Index were noted. The tooth was then removed under local anesthesia and time taken for the removal was noted. The Pederson Index, New Index and time taken were co-related using kappa statistical analysis.

RESULTS

The kappa agreement between Pederson Index and time taken was 66.50 % (0.2231) whereas between New Index and time was 89 % (0.7177) indicating that New Index is a better predictor of the difficulty.

CONCLUSION

The New Index is a reliable tool in predicting the difficulty in the removal of mandibular impacted third molar.

A simple score for evaluation of the complexity of third-molar extractions

OBJECTIVES

This article proposes a simple preoperative score to evaluate the complexity of tooth extractions of the third mandibular molar and to estimate the time involved.

STUDY DESIGN

We consider 11 factors (demographic, anatomic, and radiologic) that favor the surgery and that can be identified through standard clinical and radiologic examinations. The number of favorable factors (NFF) relative to each patient constitutes his/her score. The analysis of 1500 extractions performed by various surgeons with experience from 2 to 25 years evidences a quadratic inverse correlation between NFF and the time required for the surgery.

RESULTS

The shape of the time distribution suggests the existence of 3 major classes of patients characterized by time of 4 to 10 minutes, 11 to 20 minutes, and 21 to 40 minutes. The corresponding NFF brackets, as identified by their frequency distributions and validated by the receiver operating characteristic curve method, are 5 to 11 (mean [SD], 6.8 [1.6]), 2 to 4 (3.3 [1.3]), and 0 to 1 (0.8 [1.0]), respectively.

CONCLUSIONS

Our results show the good performance of this score as a predictor of the surgical time and its applicability in daily practice regardless of operator experience, background, and level of surgical ability.

Prediction of postoperative facial swelling, pain and trismus following third molar surgery based on preoperative variables

Objective: This paper investigates the relationship between preoperative findings and short-term outcome in third molar surgery. Study design: A prospective study was carried out involving 80 patients who required 160 surgical extractions of impacted mandibular third molars between January 2009 and December 2010. All extractions were performed under local anesthesia by the same dental surgeon. Swelling and maximal inter-incisor distance were measured at 48 h and on the 7th day postoperatively. Mean visual analogue pain scores were determined at four different time periods. Results: One-hundred eight (67.5%) of the 160 extractions were performed on male subjects and 52 (32.5%) were performed on female subjects. Median age was 22.46 years. The amount of facial swelling varied depending on gender and operating time. Trismus varied depending on gender, operating time and tooth sectioning. The influence of age, gender and operating time varied depending on the pain evaluation period (p < 0.05). Conclusions: Short-term outcomes of third molar operations (swelling, trismus and pain) differ depending on the patients’ characteristics (age, gender and body mass index). Moreover, surgery characteristics such as operating time and tooth sectioning were also associated with postoperative variables.

Key words:Third molar extraction, pain, swelling, trismus, postoperative findings, prediction.

Gender-specific differences in the central nervous system's response to anesthesia

Males and females are physiologically distinct in their responses to various anesthetic agents. The brain and central nervous system (CNS), the main target of anesthesia, are sexually dimorphic from birth and continue to differentiate throughout life. Accordingly, gender has a substantial impact on the influence of various anesthetic agents in the brain and CNS. Given the vast differences in the male and female CNS, it is surprising to find that females are often excluded from basic and clinical research studies of anesthesia. In animal research, males are typically studied to avoid the complication of breeding, pregnancy, and hormonal changes in females. In clinical studies, females are also excluded for the variations that occur in the reproductive cycle. Being that approximately half of the surgical population is female, the exclusion of females in anesthesia-related research studies leaves a huge knowledge gap in the literature. In this review, we examine the reported sex-specific differences in the central nervous system's response to anesthesia. Furthermore, we suggest that anesthesia researchers perform experiments on both sexes to further evaluate such differences. We believe a key goal of research studying the interaction of the brain and anesthesia should include the search for knowledge of sex-specific mechanisms that will improve anesthetic care and management in both sexes.

Dental general anaesthetic receipt among Australians aged 15+ years, 1998-1999 to 2004-2005

BACKGROUND

Adults receive dental general anaesthetic (DGA) care when standard dental treatment is not possible. Receipt of DGA care is resource-intensive and not without risk. This study explores DGA receipt among 15+-year-old Australians by a range of risk indicators.

METHODS

DGA data were obtained from Australia's Hospital Morbidity Database from 1998-1999 to 2004-2005. Poisson regression modeling was used to examine DGA rates in relation to age, sex, Indigenous status, location and procedure.

RESULTS

The overall DGA rate was 472.79 per 100,000 (95% CI 471.50-474.09). Treatment of impacted teeth (63.7%) was the most common reason for DGA receipt, followed by dental caries treatment (12.4%), although marked variations were seen by age-group. After adjusting for other covariates, DGA rates among 15-19-year-olds were 13.20 (95% CI 12.65-13.78) times higher than their 85+-year-old counterparts. Females had 1.46 (95% CI 1.45-1.47) times the rate of their male counterparts, while those living in rural/remote areas had 2.70 (95% CI 2.68-2.72) times the rate of metropolitan-dwellers. DGA rates for non-Indigenous persons were 4.88 (95% CI 4.73-5.03) times those of Indigenous persons. The DGA rate for 1+ extractions was 461.9 per 100,000 (95% CI 460.6-463.2), compared with a rate of 23.6 per 100,000 (95% CI 23.3-23.9) for 1+ restorations.

CONCLUSION

Nearly two-thirds of DGAs were for treatment of impacted teeth. Persons aged 15-19 years were disproportionately represented among those receiving DGA care, along with females, rural/remote-dwellers and those identifying as non-Indigenous. More research is required to better understand the public health implications of DGA care among 15+-year-olds, and how the demand for receipt of such care might be reduced.

Assessment of factors associated with surgical difficulty in impacted mandibular third molar extraction

PURPOSE

The aim of this prospective study was to investigate radiologic and clinical factors associated with increased difficulty in the removal of impacted mandibular third molars. We also aimed to form an index to measure the difficulty of removal of the impacted molars preoperatively.

PATIENTS AND METHODS

A total of 87 patients who required 90 surgical extractions of impacted mandibular third molars from November 2003 to May 2004 were involved in the study. Radiologic and clinical data were taken preoperatively. All extractions were performed under local anesthesia by a single operator. Surgical difficulty was measured by the total intervention time.

RESULTS

Increased surgical difficulty was associated with increasing age and body mass index. It was also associated with the curvature of roots of the impacted tooth and the depth from point of elevation (P < .05).

CONCLUSION

Both clinical and radiologic variables are important in predicting surgical difficulty in impacted mandibular third molar extractions.

Treatment anxiety in oral and maxillofacial surgery. Results of a German multi-centre trial

BACKGROUND

Oral and Maxillofacial operations can be extremely frightening treatment situations. General data on this phenomenon should be acquired through a multi-centre trial.

METHOD

A 10-page questionnaire was developed which was answered by 600 oral and maxillofacial patients before individual treatment. Control groups consisted of 800 surgical, dental and general practitioners/internal medicine patients. Twenty six medical practices and hospital departments in 11 German cities were involved in the trial.

RESULTS

Both subjective anxiety assessment by patients and objective testing (State Trait Anxiety Inventory; STAI) indicated a high level of treatment anxiety for oral and maxillofacial treatment situations. Oral and Maxillofacial Surgery (OMFS) patients' scores were significantly higher than those of control groups. Especially younger and female patients, patients treated under local anaesthesia and out-patients showed intensive anxiety. Previous treatment experience in OMFS did not modify test results.

CONCLUSION

Managing perioperative anxiety is still a major challenge in OMFS. Irrespective of technical, pharmacological and surgical advances, developing and establishing stress-reducing and anxiolytic perioperative techniques is of considerable importance for both patients and surgeons.

Relationships Between Surgical Difficulty and Postoperative Pain in Lower Third Molar Extractions

PURPOSE

To investigate the influence of surgical difficulty on postoperative pain after extraction of mandibular third molars.

MATERIALS AND METHODS

A prospective study was performed of 139 patients who underwent a total of 157 mandibular third molar extractions. For evaluation of surgical difficulty, a 4-class scale was completed after surgery: I, extraction with forceps only; II, extraction requiring osteotomy; III, extraction requiring osteotomy and coronal section; IV, complex extraction (root section). The duration of surgery was also recorded. Postoperative pain was evaluated using a visual analog scale that each patient completed daily until day 6 postsurgery, at which time the sutures were removed.

RESULTS

A statistically significant relationship was observed between surgical difficulty (as rated on the scale) and postoperative pain. Longer interventions generally produced more pain.

CONCLUSIONS

Pain after extraction of a mandibular third molar increases with increased surgical difficulty and duration of the intervention.

[Treatment anxiety in oral and maxillofacial surgery]

BACKGROUND

Oral and maxillofacial operations are stressful treatment situations for patients. Specific data on this phenomenon were acquired through a multicenter study.

MATERIAL AND METHODS

A 10-page questionnaire was answered by 600 oral and maxillofacial patients before individual treatment. Control groups consisted of 800 surgical, dental, internal medicine and general practitioner patients. 26 practices and hospital departments in 11 German cities were involved in the study.

RESULTS

Both subjective anxiety assessment by patients and objective measurement (State Trait Anxiety Inventory; STAI) indicated a high level of treatment anxiety for oral and maxillofacial treatment. STAI scores for OMFS patients were significantly higher than in control groups. Especially female patients, patients treated under local anaesthesia and out-department patients showed high anxiety scores. Treatment experience in oral and maxillofacial surgery does not modify anxiety in case of recurrent treatment.

CONCLUSION

Managing perioperative anxiety today is still a major challenge in oral and maxillofacial surgery. Irrespective of technical and pharmacological advances further studies on this topic and the development and establishing of stress-reducing and anxiolytic perioperative techniques are of considerable importance.

Removal of third molars in Scottish oral and maxillofacial surgery units: A review of practice in 1995 and 2002

We audited the practice of removal of third molars in Scottish oral and maxillofacial (OMFS) units in 1995 and in 2002. We collected data from anonymous structured postal questionnaires from 12 Scottish OMFS units about patients referred for removal of third molars in 1995 and 11 units in 2002. The percentage of patients who had no treatment increased from 11% in 1995 (102/928) to 16% in 2002 (66/412). The incidence of prophylactic removal of third molars decreased between the two periods. Removal of third molars under local anaesthesia with or without sedation increased from 35% (325/928) in 1995 to 54% (223/412) in 2002. Removal of third molars under general anaesthesia decreased from 54% in 1995 to 30% in 2002.

Recovery of dynamic balance after additional small divided doses of midazolam given intravenously for sedation

We have previously reported that a dynamic balance test with perturbation stimuli and computerised dynamic posturography sensitively reflected the inhibitory effect on balance of intravenous midazolam sedation given intravenously as a single dose, and recovery time was within 80 min. The purpose of this study was to investigate the recovery of dynamic balance after additional doses of midazolam. Eighteen young adult male volunteers were sedated with midazolam given intravenously. The initial dose was given until the Wilson sedation score reached 3, and an additional dose was given until the same score was obtained 40 min later. They were tested with perturbation stimuli 40, 80, 100, and 120 min after the additional doses had been given. Their recovery time was recorded. The mean (S.D.) initial dose of midazolam was 0.07 (0.005) mg kg(-1), and additional doses were 41 (7)% of the initial dose. The serial changes in bispectral index after initial and additional doses were similar. The recovery time for the dynamic balance test (within 80 min) was the same as that recorded in the previous single-dose study. The recovery time of the psychomotor function test was within 75 min. Additional doses of midazolam aiming for a Wilson sedation score of 3 at a dose about 40% of the initial dose and given 40 min after the initial dose are valid in terms of the maintenance of sedation and recovery of dynamic balance. Complete recovery time, including psychomotor function, was within 80 min of the additional dose of the drug.

Types, frequencies, and risk factors for complications after third molar extraction

OBJECTIVES

The study objective was to identify the types, frequency, and risk factors for complications after third molar (M3) extractions.

STUDY DESIGN

This retrospective cohort study consisted of patients who had 1 or more M3s removed between 1996 and 2001. Risk factors were grouped into demographic, general health, anatomic, and operative. Outcome variables were operative or inflammatory complications. Data were analyzed using descriptive, bivariate, and multivariate statistics.

RESULTS

The study sample was composed of 583 patients (57.0% male) with a mean age of 26.4 +/- 8.4 years. The overall complication rate was 4.6%. Increasing age, a positive medical history, and the position of the M3 relative to the inferior alveolar nerve were associated with an increased risk for complications.

CONCLUSION

While age, medical history, and M3 anatomy cannot be altered directly, these factors may be modified indirectly, resulting in a potential decrease for postoperative complications.

A comparison of 2 consultation and treatment strategies to manage impacted third molars

PURPOSE

This study compares the postoperative complication rates of 2 strategies for the evaluation and operative management (E&M) of patients with impacted third molars (M3s).

MATERIALS AND METHODS

We used a retrospective cohort study design and a sample composed of patients who had M3s extracted between 1985 and 2000. The predictor variable was the E&M strategy defined as 1) same-day surgery (SDS) in which the consultation and procedure were performed on the same day and 2) consult prior to surgery (CPS) in which the consultation and procedure were separated in time by more than 24 hours. The outcome variable was postoperative complications. Descriptive and bivariate statistics were computed and a multivariate model was developed to measure the relationship between E&M strategies and postoperative complications.

RESULTS

The sample was composed of 5,993 patients (mean age, 23.7 years; 61% female), and 1,556 patients (26%) were classified as having SDS. Overall, 36% of patients reported one or more postoperative complications. Variables included in the multivariate model were E&M strategy (SDS or CPS), age, gender, number of M3s removed, tobacco exposure, and type of anesthesia. Based on the results of the multivariate model, SDS was not associated with an increased risk for postoperative complications (P =.08).

CONCLUSIONS

Optimal operative management of M3s would minimize the number of visits, maximize operator efficiency, and minimize morbidity. In comparison with CPS, SDS minimizes the number of patient visits without an increased risk for complications.

Links between anaesthetic modality and nerve damage during lower third molar surgery

OBJECTIVE

To investigate the relationships between eruption status, gender, social class, grade of operator, anaesthetic modality and nerve damage during third molar surgery.

DESIGN

Two centre prospective longitudinal study.

SETTING

The department of oral and maxillofacial surgery, University Hospital Birmingham NHS Trust and oral surgery outpatient clinics at Birmingham Dental Hospital.

SUBJECTS

A total of 391 patients had surgical removal of lower third molars. Sensory disturbance was recorded at one week post operatively. Patients with altered sensation were followed up at one month, three months and six months following surgery.

RESULTS

614 lower third molars in 391 patients were removed. Forty-six procedures (7.5%) were associated with altered sensation at one week with three procedures (0.49%) showing persistent symptoms at six months. Of these 46 nerve injuries, 26 (4.23%) involved the lingual nerve and 20 (3.25%) the inferior dental nerve (IDN). All three persistent sensations were IDN related. A logistic regression model found that the use ofa lingual retractor chi2 = 11.559, p = 0.003 was more significant than eruption status chi2 = 12.935, p = 0.007. There was no significant relationship between anaesthetic modality, age, social class, sex and seniority of operator.

CONCLUSIONS

There was no link between the choices of local or general anaesthesia and nerve damage during lower third molar removal when difficulty of surgery was taken into account.

Factors predictive of difficulty of mandibular third molar surgery

AIM

Historically the difficulty of third molar surgery has been judged using radiologically assessed dental factors specifically tooth morphology and position. This study investigated additional factors that have a bearing on the difficulty of extraction.

STUDY DESIGN

A prospective study undertaken by three clinical assistant grade surgeons who removed 354 single mandibular third molar teeth under day case anaesthesia over the 4-year period (1994-1998).

METHOD

Data relating to patient, dental and surgical variables were collected contemporaneously as the patients were treated. The difficulty of extraction was estimated by the surgeons pre-operatively using dental radiographic features and compared by the same surgeon within the actual surgical difficulty encountered at surgery. Operation time strongly related to both pre and post treatment assessments of difficulty and proved to be the best measure of surgical difficulty.

RESULTS

Univariate analysis identified increased patient age, ethnic background, male gender, increased weight, bone impaction, horizontal angulation, depth of application, unfavourable root formation, proximity to inferior alveolar canal and surgeon as factors increasing operative time. Multivariate analysis showed that increasing age (P = 0.014), patient weight (P = 0.024), ethnicity (P = 0.019), application depth (P = 0.001), bone impaction (p=0.008) and unfavourable root formation (P = 0.009) were independent predictors for difficulty of extraction.

CONCLUSIONS

Half of the six independent factors that predicted surgical difficulty of third molar extraction were patient variables.

A study of anxiety, and midazolam-induced amnesia in patients having lower third molar teeth extracted

We studied 60 patients to find out whether anxiety affects the dose of midazolam necessary for sedation, and whether operating time, dose of midazolam, or technique have any influence on levels of amnesia and anxiety. A pilot study preceded the main study in which 20 patients were given local anaesthesia only and 20 local anaesthesia and intravenous sedation. Patients in the main study group (n = 60) received both local anaesthesia and intravenous sedation. The dose required for sedation was not linked to amnesia, pulse rate, blood pressure, or preoperative anxiety. Sedation did significantly reduce postoperative anxiety scores, (P< 0.001) and amnesia was affected by operating time; complete surgical amnesia seemed to last about 25 minutes.